Wrist/Hand Pain with Radiating Pain Flashcards
Pathoanatomy
What are other structures that pass through the Carple Tunnel other than the Median Nerve?
- 4 tendons of FDS/FDP
- Tendon of FPL
The Median nerve lies just beneth the flexor retinaculum/transverse carpal ligament
Clinical Practice Guideline for Carpal Tunnel Syndrome
What is the Cluster for Diagnosis for Carpal Tunnel Syndrome?
- Age >45 years old
- Shaking hands to relieve symptoms
- Sensory loss on thumb
- Boston Carpal Tunnel Questonnaire-symptom severity scale >1.9
3+ positive: sensitivity, 0.98 and specificity 0.54
Subjective History
What are reported findings for patients with Carpal Tunnel?
- Numbness, tingling, pins and needles in the median nerve distribution
- Symptoms ususally worse at night; May disturb sleep
Pt. may be sleeping with the wrist in a position that may tension or compress the median nerve. which may lead to complaining of the pain that wakes them up - Difficulty picking up small objects
- Symptoms aggravated by postures of wrist flexion and extension (stretch or compression of neurovascular bundle)
- Hx of distal radius fracture
Majority of cases will present bilaterally
What are Occupational Risk Factors for Carpal Tunnel?
- The use of vibratory tools
- Repetitive movements of the hand/wrist
- Intense computer use of at least 12 to 20 hours per week
What is commonly associated with Carpal Tunnel?
- Diabetes
- Obesity (BMI >25kg at least 2x risk)
- Increasing age
- Female Gender(1.5-4x more likely)
- Pregnancy
DM and Obesity are comobilities
Specific Test and Measures for Carpal Tunnel
How may posture affect Carpal Tunnel?
What in the hand should we check (Think motor)?
- Posture should be evaluated, and sustained postures should be considerd that may be adding stress to the median nerve.
-This could mean sleeping positions or workstation environments
-The pt should take a picture of themselves while they work so we can do an ergonomic assemssment.
-Ask how the pt sleeps, they may need a brace at night to avoid excessive wrist flx/ext. - We must also check for Thenar Muscle atrophy; If there is significant muscle wasting, either the compression is really severe or its been going on for a long time. In these cases the pt needs more immediate decompression surgery
Specific Test and Measures for Carpal Tunnel
What may you find during the Joint Integrity examination?
This may reveal mobility limitations of the carpals of at the wrist joint
Specific Test and Measures for Carpal Tunnel
What may you find during A/PROM examination?
Wrist A/PROM may be altered or symptomatic at end-range wrist Flx/Ext.
Specific Test and Measures for Carpal Tunnel
What may you find during the strength assessment?
- Weakness in muscles with motor innervation to median nerve
- Weakness in grip strength
Specific Test and Measures for Carpal Tunnel
What may you find during the muscle length assessment?
May have altered length of wrist flexors and extensors
Specific Test and Measures for Carpal Tunnel
What will you find during the Neuro assessment?
- Pain or paresthesia in median neve distribution
- (+) ULNT 1
Specific Test and Measures for Carpal Tunnel
What special test would this patient most likely be positive for?
- (+) Phalen’s
- (+) Tinel’s on Carpal Tunnel
Specific Test and Measures for Carpal Tunnel
What should be done for the Movement Analysis for this patient?
- Occupational related activities
- Gripping
Specific Test and Measures for Carpal Tunnel
What are the Median Nerve Entrapment sites that should be palpated to rule in/out?
- Bicep Aponeurosis
- Ligament of Struthers
- Pronator Teres
- Carpal Tunnel
What are Associated Impairments with Carpal Tunnel?
- Scapular Movement Faults
- Periscapular Strength and scapulohumeral rhythm
- Cervical or Thoracic Mobility Deficit (Espeically sensitivity at C5/C6 segments)
- Deep Neck Flexor Assessment
Must also consider ergonomic and sleeping positions
What is the Prognosis for Carpal Tunnel?
- Most tissues take about 6 weeks to heal (8-12 visits)
- Healing time also depends on the health of the pt and the ability to avoid aggravating factors
- Check for signs of atrophy, they are more likely a surgical canidate
Interventions for Carpal Tunnel
What are Manual Therapy Interventions that can be done?
- Myofascial release (MFR) /STM or manual stretch
- Graded mobilization
Interventions for Carpal Tunnel
What are Therapeutic Exercises that can be done with pts with carpal tunnel?
- ROM
- Postural training
- Addressing associated impairments
- Improving Neurodynamics
Interventions for Carpal Tunnel
What are Motor Function Movement Training exercises that can be done with pts with Carpal tunnel?
- Deep Neck Flx training
- Scapular muscle training and/or mobility
Interventions for Carpal Tunnel
What Functional Training can be done with pts with Carpal Tunnel?
- Sleep training/positioning
- Posture, ergonomics
Interventions for Carpal Tunnel
What Modalities can be used with Carpal Tunnel?
- Neutral/Cock-up wrist splint
- Ultrasound
- Lasar
What type of Orthosis would be used for patients with Carpal Tunnel?
Wrist Controlled Orthosis (WHO)
What is Ulnar Tunnel Syndrome?
This is entrapment of the Ulnar Nerve at Guyon’s Canal (around pisohamate ligament)
If we suspect a patient has Ulnar Tunnel Syndrome, what should we ask them?
Whether they have any medical Hx involving diabetes and peripheral neuropathies
